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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> pin <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1017/7 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San ,Joaquin Local Health District for a permit to construct <br /> and/or install the work herein, described.. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> �r <br /> JOB ADDRESS/LOCATION d �a /�f C.L 2 E9C)9 LoAJ CENSUS TRACT <br /> Owner's Name �,�Q �. (Q J.- ! _rp. TRI Phone 1, E 4 _ <br /> Address _ :S{%ME' City UC_"O_A ^ <br /> Contractor's Name G- a I L L f rd 4 License # ;�5`6O4 Phone 8q7-4 ?l r <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ / RECONDITION- / / DESTRUCTION / .7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 SEWER LINES PIT PRIVY .�-- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/S EPAGE PIT OTHER '~ � t <br /> PROPERTY LINF/t0PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1�. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �( Domestic/private W , Drilled Dia. of Well `Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protectionjy Rotary Type of Grout <br /> Disposal Other Other Information _ <br /> Geophysical I� Surface Seal Installed By: a o j <br /> PUMP INSTALLATION: ContractorV"Q� <br /> Type of Pump H.P. <br /> _ a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES TRS UCTION OF WELL: Well Diameterl <br /> Approximate Depth �^ <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />: after completion of my work on a new well., I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS. REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. . I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUPING AND A _FINa. _ I1j$PECTION. <br /> SIGNED TITLE <br /> (D94W PLOT PLAN ON REVERSE SIDE) <br /> PHAGE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY *ell DATE <br /> ADDITIONAL:, COMMENTS <br /> PHASE IIPb SP TION PHASE I T/FINAL INSPECTION <br /> INSPECTION BY DATE J INSPECTION BY BATE - . <br /> E H 1426 Rev, . 1-74 -' �� jy}, 1 n� foo l ren F_ b/7.7 _ 2M <br /> 4 <br />